Registered Nurse - Utilization Review

Job Title

Employment Type: Full time

Shift: Rotating Shift

Description: This is a remote position but will need onsite training in Mishawaka Indiana. Shift: Days - 8 hr shift LOCAL CANDIDATES ONLY!

Why Choose Saint Joseph Health System?

At Saint Joseph Health System, our values guide every decision we make. Even when challenges arise, we remain committed to our mission: caring for every person who needs us. We invest in our people, our technology, and our capabilities so we can continue delivering exceptional, compassionate care to our communities.

What We Offer

• Tuition reimbursement for all full-time and part-time colleagues starting on day one
• Comprehensive benefits beginning day one (Medical, Dental, Vision, PTO, Life Insurance, STD/LTD, and more)
• Retirement savings plan with employer match
• Generous paid time off program plus 7 paid holidays
• No mandatory overtime
• Employee referral incentive program
• Access to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environment

What You Will Do

• Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
• Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
• Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records, compile reports, and support utilization review program operations
• Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
• Support compliance with all regulatory, accreditation, and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

What You Will Need

• Graduate of an accredited Registered Nurse (RN) program; Bachelor's Degree in Nursing preferred
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Prior utilization review, case management, or payer review experience preferred
• Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
• Solid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operations
• Excellent communication skills with the ability to collaborate effectively across teams
• Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
• Proficiency in computer systems and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced healthcare environment
• Flexibility to adapt to changing schedules, workflows, and departmental needs

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.